Form LD 2 - Checklist on Learning and Behavior Characteristics

(CLBC)
Name: _____________________________________________ Age: ____________ Grade Level: __________
Sometimes Most of the All of the
CHARACTERISTICS (1 point) Time Time
(2 points) (3 points)
I. Learning Characteristics
A. Spelling
1 Uses incorrect letter order
2 Cannot spell correctly at grade level
3 Cannot write from dictation at grade level
4 Reverses letters or entire words

B. Writing
1 Cannot write name or other information
2 *Cannot stay on line
3 Cannot copy simple sentences from the board
4 Cannot write simple sentences from dictation
5 Cannot do regular work in writing for the grade

C. Reading
1 Does not like to read
2 Loses place when reading
3 Repeats, omits or adds words
4 Cannot read the DOLCH words for grade level
5 Uses fingers to follow a line
6 Cannot understand/remember what he/she reads

D. Mathematics
1 Has difficulty associating numbers with symbols
2 Reverses two-place numbers (13 for 31 or vice versa)
3 Cannot recall math facts at grade level
4 Fails to comprehend math concepts
5 Gets confused with written and/or oral arithmetic

E. Hearing/Speech
1 Does not seem to listen when spoken to
2 Cannot follow oral direction
3 Has articulation problems; wrong pronunciation of words; speech not clear
4 Has infantile (baby) speech

F. Psychomotor
1 Displays poor motor coordination in using scissors, crayons, pencil, etc
2 Confuses right from left and vice versa
3 Lacks rhythm in movement, loses sequence and balance;
has difficulty walking in straight line
4 Has difficulty buttoning, zipping and snapping, articles of clothing;
skipping, hopping, climbing
II. Behavior Characteristics
1 Tends to be impulsive, hits classmates, reacts immediately to situations
without thinking, impatient; cannot wait for his/her turn
2 Demands individuals attention through overt behavior tactics
3 Rushes through assignments with little or no regard for accuracy, quality
of work and neatness
4 Does not direct attention to or cannot maintain attention to important sounds
in the immediate environment, teacher's directions, public addresses, etc.
5 Has short attention span, has difficulty concentrating on tasks (e.g. More
interested in other activities, sits and does nothing, etc.)
6 Stays out of seat; engages in over active behavior
Additional Information about the Pupil

Scoring and Interpretation of Results

Scoring Procedure:

1. Add the number of checkmarks in each column and multiply the sum by the number of points.

Sometimes - - - - - - - - - x 1 point
Most of the time - - - - - - x 2 points
All the time- - - - - - - - - - x 3 points

2. Write the score using the following ranges and interpretation.

Interpretation:
75 to 105 points
50 to 74 points
35 - below points
= Manifests almost all of the LD characteristics
Recommend for multi-factored assessment
= Manifest most of the LD characteristics
Recommend for multi-factored assessment
= Manifest some of the LD characteristics
Can benefit from regular class instruction

______________________________
Observer
Form LD 4 - Individual Report on Pre-Referral Screening (IR-PRS)

Name: _____________________________ Grade: _____________ Age: _________

School: _____________________________ Address: _________________________
Home Address: ___________________________________________Tel.#:_________
Name of Parents:______________________________________________

Initial Screening Score: ______________ Interpretation: _____________________

Learning Characteristics:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Behavioral Characteristics:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Recommended for multi-factored assessmentYES NO

Other Observations:

Teacher's Name & Signature

Date of conduct: __________________________
 Form LD 5a - Child's Profile: Case History Form (CHF)

CHILD'S PROFILE

Child's Name: _____________________________ Sex: _____ Date of Birth: _________ Age: ______
School: _________________________________ Address: ________________________________
Home Address: ______________________________________________ Tel.#:________________
Reasons for Referral:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

1. GENERAL
Father's Name: _____________________________Birthday:_____________Age: ________________
Address: _________________________________ Education Completed: _____________________
Occupation : _____________________________ Name of Employer: ________________________
Office Address: ______________________________________________ Home Phone: _________

Mother's Name: ____________________________ Birthday:_____________Age: ________________

Address: _________________________________ Education Completed: _____________________
Occupation : _____________________________ Name of Employer: ________________________
Office Address: ______________________________________________ Home Phone: _________

Siblings
Name: __________________________________ Sex: ______________ Age: __________________
Name: __________________________________ Sex: ______________ Age: __________________
Name: __________________________________ Sex: ______________ Age: __________________
Name: __________________________________ Sex: ______________ Age: __________________
Name: __________________________________ Sex: ______________ Age: __________________
Name: __________________________________ Sex: ______________ Age: __________________

Presence of (M for Mother, F for Father, S for Sibling, G for Grandparent, R for other relatives)

• Hearing Loss: ____________

• Epilepsy:________________
• Mental Retardation:________
• Substance Abuse: ________
• Fragility: ________________
• Speech Impairment (specify): ______________
• Behavior Problems (specify): ______________
• Academic Difficulty (specify): ______________
• Specific Learning Disorder (specify): ________
• Others (specify): _________
 Teacher's Name & Signature
Date of conduct: __________________________
 Form LD 7 - Rating Scale for Teachers (RST)
on Learning Disability

Name: ____________________________________ Age: ___________Sex:____________

School: ___________________________________ Grade: _________________________

Direction: Rate each behavior following the scale below.

0 - - - - - -Never manifested
1 - - - - - -Sometimes manifested
2 - - - - - -Manifested most of the time
3 - - - - - -Manifested all the time

I. Academic Behaviors
1. Spelling
________1) Uses incorrect letter order
________2) Has difficulty associating the correct sound to the letter or blend
________3) Reverses letters or entire word
2. Writing
________4) Cannot write on the appropriate line
________5) Very slow in writing production
________6) Cannot copy (especially from the board)
________7) Uses capital and small letters inappropriately
3. Reading
________8) Loses place in a line while reading
________9) Repeats, omits or add words
________10) Does not read fluently
________11) Confuses similar words or letters as to visual configuration
________12) Uses fingers to follow the line while reading
________13) Dislikes reading
________14) Shows indications of poor reading skills, but not necessarily in all areas
________15) Has difficulty understanding or remembering what is read to him
________16) Has difficulty remembering the sequence of events of a story read
4. Mathematics
________17) Has difficulty associating number with symbol
________18) Cannot recall Math facts instantly
________19) Shows confusion with columns and spacing
________20) Has difficulty wth story problems
________21) Fails to comprehend Math concepts
________22) Has difficulty in the formation of geometric shapes and numbers
________23) Makes reversals of numbers in writing and/or reading after sufficient instruction and practice
________24) Demonstrates confusion with written and/or oral arithmetic
5. Hearing/Speech
________25) Show indications of delayed speech
________26) Has trouble/difficulty following oral directions
________27) Does not often seem to listen when spoken to
________28) Has poor listening skills
________29) Has articulation problems
II. Motor Behaviors
________30) Shows clumsy movements on the play ground and/or in classroom; for example,
constantly tripping over chairs, running into play equipment, etc.
________31) Has difficulty hopping, skipping, jumping, walking, and climbing stairs, which may
indicate immature physical development
________32) Has difficulty walking in straight lines and/or balance beams
________33) Has difficulty buttoning, zippering and snapping articles of clothing
________34) Cannot easily cut with scissors
________35) Holds crayons and pencils awkwardly
________36) Demonstrates confusion with direction of left, right, up, down, in front, behind, etc.
________37) Is not aware of relationships between his physical beings and his surroundings, for
example not judging distances properly

III. Social Behaviors

________38) Demonstrates confusion when changes are made in any daily routine
________39) Unusually sloppy
________40) Demonstrates destructive behavior over belongings
________41) Tends to be easily distracted by visual or auditory stimuli
________42) Maybe demanding or attracts individual attention through overt behavior tactics,
for example, loudly interrupting teacher or others in the middle of class activities
________43) Has difficulty in getting along with peers and/ or adults
________44) May show indications of certain physical characteristics such as nervousness, startled
movements, uneasiness when sitting for even a short period of time, etc.
________45) May pout or cry easily with very little reason
________46) May exhibit flighty or erratic behavior such as getting up in the middle of a work period to dance around
________47) May tell tales or bizarre stories to peers and/or teacher
________48) Has an unusually short attention span for his/her age

SCORING:
1. To get the score, add the number of 0s, 1s, 2s, and 3s and multiply them by 0, 1, 2, and 3 respectively.
2. Get the sum of the scores.
3. Write the scores using the ranges and interpretation below.

INTERPRETATION:

100 - 156 = Manifests almost all of the characteristics

Recommend for multi-factored assessment
60 - 99 = Manifests most of the characteristics
Recommend for multi-factored assessment
30 - 59 = Manifests some of the characteristics
Can benefit from regular class instruction
Below 30 = Negligible
Can benefit from regular class instruction
______________________________
Observer
as getting up in the middle of a work period to dance around
 CHECKLIST ON HANDWRITING SKILLS
on Learning Disability

OK NEEDS
REVIEW

1. Performance Observation
Pencil is held properly - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Paper is positioned at a 'normal' slant - - - - - - - - - - - - - - - - - - - - - - - - - - -
Writing posture is acceptable - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Writing speed is acceptable - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
2. Correct Letter Formation
Closed letters are closed - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Looped letters are looped - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Stick letters are not looped - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
i and j are dotted directly above - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
x and t are crossed accurately - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
m and n have the correct number of bumps - - - - - - - - - - - - - - - - - - - - - - -
All lowercase letters begin on the line (unless they follow b, o, v, or w) - - - - -
b, o, v and w end above the line - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
All lowercase letters end on the line - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
v and u are clearly delineated - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Connecting strokes of v and y are clearly not ry and ry - - - - - - - - - - - - - - -
Uppercase letters are correctly or acceptably formed - - - - - - - - - - - - - - - -
Numbers are correctly formed - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
3. Fluency
Writing is smooth not choppy - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Pencil pressure appears even - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Words appear to be written as complete units - - - - - - - - - - - - - - - - - - - - - -
Letter connection is smooth - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
4. Letter Size, Slant and Spacing
Lowercase letters are uniform in size - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Uppercase letters are clear - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Uppercase letters are uniform in size - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Tall lengths are consistent and do not interfere with letters on the line below -
Writing is not too small or too large - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Slant of letters is acceptable - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Slant of letters is consistent - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Spacing of letters and words is consistent - - - - - - - - - - - - - - - - - - - - - - - - -
5. Student Attitude toward Writing
Student's opinion of his writing skills
"Writing is hard" - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Writes too slowly - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Feels good about writing - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
6. Overall Teacher Evaluation
You appear to write smoothly and easily. Your letters are formed correctly.
Letter size, slant and spacing are good. Your writing is neat and legible.
It is not necessary for you to complete the handwriting exercises.
 You appear to write smoothly and easily. You have developed your own writing style, which
is legible and neat. It is not necessary for you to complete handwriting exercises.
You appear to write smoothly and easily. However, your letter formation, neatness and
legibility needs some work. Please complete the handwriting exercise.
Writing seems to be difficult for you. You need practice in handwriting skills. Please
complete the handwriting exercises.

______________________________
Observer